Friday, August 14, 2009

The suicide attempter**

An interesting permutation of the thesis on suicide versus accident comes from the person who is the suicide attempter. One hears stated that there are two main groups who exhibit suicidal type behaviour.

The suicidal person

The suicide attempter

They have different motives. The suicidal person wants to die and the ‘suicide attempter’ does not want to die. However the suicide attempter can die by accident in that they did not mean for the suicide attempt to be completed.

I had an example of that happen recently. A woman in her early 20s had sent an email to her boyfriend that she had taken an overdose. She knew he was very likely to get the email and save her as he had done so a number of times before. He never got the email and she died. As she had a history of doing this one can conclude that her motive was not to kill self. Her goal was to manipulate him to act a certain way which had worked on many occasions before. She wanted him to come and save her thus demonstrating his love for her in her mind.

Would this grab your attention if you saw it? I think so.

However one needs to look at this situation more closely. If in her attempts at suicide she engages in acts that are highly dangerous then she is repeatedly engaging in high risk behaviour. On suicide risk assessment scales she would score on this point thus indicating that she is possibly suicidal to some degree.

It seems that the type of suicide attempt is significant for understanding the suicide attempter. If the attempts are clearly non-lethal then one can more safely conclude that the person is not motivated to kill self. They are making suicidal gestures for other reasons such as a cry for help or to manipulate others.

If the attempts are potentially quite lethal then the situation is less clear. Whilst the person may be acting in a suicidal way to gain attention there may also be some genuine desire to kill self. The individual may have made the suicide decision in childhood and thus in the psychological sense be ‘truly’ suicidal. However they may also have other motives as well such as manipulation and so forth. If they die in one of these suicide attempts then it may be partially a suicide and partially an accident. They are both a suicidal person and a suicide attempter at the one time.

Indeed one could argue that all suicidal people are suicide attempters to some degree because of the idea of suicidal ambivalence. I have postulated this before.

All suicidal individuals are ambivalent to some degree. They all have an internal dialogue which states: “I do want to die vs I do not want to die”.

All suicidal people have this contradictory set of thoughts and urges inside self. If a person is 100%, “I do want to die” then it wont be too long before they are. If a person is 100%, “I do not want to die” then there would be no suicidal thoughts or urges in the first place. The suicidal individual has percentages of both with the levels waxing and waning over time. Sometimes it will be 50/50 and then on other days it might be 60/40 or 30/70.

The individual shown in the diagram above would be classed as a suicidal person not a suicide attempter because they have made the suicide decision which is known in Transactional Analysis terms as the “Don’t exist” injunction. However they also have a Free Child aspect of their personality and thus they don’t fully want to die. So their suicidal actions are therefore at least at times going to be half hearted, quarter hearted or third hearted depending on how much energy is in the FC and how much in the AC at the time of the attempt.

For instance a man reported to me a suicide attempt of a few years ago. He plunged a large fishing knife into his abdomen, then rang his mother on the phone. He could have very easily died and almost did. He definitely had made a suicide decision in early life and his AC energy was high at the time of the attempt. However he also rang his mother which in my view was an expression of his Free Child desire to live. So in this way one could say he was a suicide attempter and he was trying to manipulate his mother.

Well the Aussies certainly evened up the cricket! One all now and the poms have to win to the decider to get the ashes!

You ask an interesting question about the FC and want to die. Obviously the FC is merely a theoretical construct. All of us who are alive, have a want to live in our personality and I think it is safe to say that most would see that as a function on the Free Child aspect of the personality. So in that way the desire to suicide would not be a function of the FC. However if on considers something like euthanasia or as it is called here - assisted suicide - which is an interesting term in itself as it questions the definition of what suicide actually is.

If ones quality of life is very poor due to say physical infirmity and yet one is still mentally capable then the desire to die could be argued as being a FC function.

As to the question of the suicide decision. In the formation of our life scripts we make a series of what are called “Early decisions” usually seen as occurring within the first decade of life. So from this theory all decisions including the suicide decision would be made early in life.

If in adulthood a person is placed in highly traumatic circumstances then that can have a significant impact on a person. That is, the person’s personality can be significantly effected for the rest of their days. Life script theory could argue that this person made a new decision because of the trauma which obviously is not an ‘early decision’. So theoretically a person could make a suicide decision when they are say 30 years old.

However, there could also be a strong argument that the suicide decision made at thirty would not really be a new decision. It would simply be exaggerating an already existing early decision. When traumatised at age 30 the person could make ‘new’ decisions that are consistent with their early decisions they made. So if a person made a ‘little’ suicide decision in childhood and then at 30 they could make a new much bigger suicide decision. So that leaves one with the question of, is making a small decision a bigger one at 30, really a new decision or not?

So that's why i'm so different now when compared to the person of 8 or so years ago?

I'm not so much fun anymore; don't like to go out alot; don't find the same things funny because i see lots of things differently now; mood swings; terribly honest to the most unsustpecting people most of the time (before i didn't have a problem with almost anyone but now - i'm like a rabid dog with most people most of the time); I don't laugh anymore (used to laugh all the time and i mean ALL the time); when i get sad now, its like a sadness i'd ever thought could exist (its not just sad anymore, its like being physically abuse or belted all over my body and inside too).

But i'm alive.

To read or study anything Psychic is a major undertaking but i think most people could do it and have quite an extensive knowledge or understanding (theoretically that is) about the human condition. But to live and feel it? Tony, its horrific and beautifuly wonderful, all at the same time. It can erupt a brilliant smile from the joy of living and yet erode your insides despairingly simultaniously.

We are definately not what we seem to be, that's for sure, but what the heck are we? I don't understand but to live every aspect?; from the mountain top experience to the deepest loneliest blackhole dread - i don't know how we survive this thing called life.

Yeah, I want to know more about that too. I do think that I made the decision very young...but what does that mean? When/why/how is that decision made (not consciously)? What kind of junction goes on in a very young mind? Concrete examples, please, I never get the theory. What is AC exactly?

It's funny, with the new counselor this kind of thing has been on my mind a lot...that all of this stuff that is going wrong lately started decades ago.

About suicidality, I always promised myself that if I do anything, I better mean it and complete it. If not, I'm just fucking around. Never have attempted, but promised myself that if I do, it would be by lethal means. Not sure if that is something protective or dangerous.

Hi Sara,AC stands for Adapted Child ego state. The person perceives in childhood the parents telling her that things would be better if she was dead. So when she adpats to this message (injunction) in adulthood she will display suicidal behaviour.

Do you have a new counsellor?

To my mind an uncompleted attempt that leaves the person with significant permanent damage is the worst outcome.

This is relevant to my life right now because I am currently in training to become a crisis hotline volunteer. There are people who call the hotline because they are suicidal. It seems to me that anyone who makes the call wants an intervention, whether they are in the ideation phase, the planning phase, or have actually started an attempt. Someone who truly wants to die will not make a call. That puts a lot of pressure on the person who is called! But it's also a positive sign if someone calls, it means they really want help. Or are manipulating, but we are trained to view them as wanting help.

If you don't mind me asking, Tony, and you don't have to answer, have any of your patients ever committed suicide besides the young woman you mentioned in this post?

Good on you for doing the crisis hotline! The point I was making above. If someone calls the hotline and they have made an attempt that is clearly non-lethal then it seems more likely that they have some motive other than actually dying. If they have made a highly lethal attempt then it seems likely that they would have made the suicide decision and their motive is to die. However even these people still have some FC desire to stay alive so one ends up with contradictory behaviour in such people. Like the guy I described above with the fishing knife.

When he stabbed himself he was making a very definite statement of “I want to die” and then he phoned hs mother (“I don’t want to die”) and because of her actions he is alive today.

To the best of my knowledge I have not had a client of mine take there own life (sort of). There are clients who I have seen who suddenly stop coming and I just never hear from them again. It is possible some of them have but it has never been reported to me. There was one woman whom I saw for about 5 years and she abruptly terminated treatment and a month later she suicided. Was she my client still? Some would argue yes and some would argue no.

The woman in the post was somewhat of an unusual circumstance. When working overseas I got to know her father quite well. A few years later his daughter who was a student in Australia came to see me for counselling. I saw her a number of times and she told me about how she would make attempts and then contact her boyfriend. Then she finished counselling and I did not see her again. About 2 years later her father and her mother were in Australia and made an appointment to see me. They came and told me that she had recently suicided and the circumstances of that and just wanted some information from me and so forth.

I do have a new counselor. Not sure it will work out but at least it's solid...

And yes, I could imagine, not quite my father telling me it would be better if I were dead...but certainly at times him being so miserable that he would have been better off dead...the message that life basically sucks and is scary and miserable came through loud and clear. The stated message was that I was supposed to be this super genius kid who would do everything he failed at...but the other message was that everything was miserable all the time.

And also that anything I might want was useless. I was going to be what he wanted me to be, period. Nothing of my needs or wants was relevant, and, in fact, whenever I expressed them, I was harshly punished (ie hit with iron when I stated that I didn't want to go to the special education program in second grade). Maybe that's a kind of "don't exist" command.

There certainly wasn't any example of a normal adult in my life. From a very early age, I saw life as a series of shit I had to get through. I wanted to get through school and home life and figured always that after I got out of that situation I'd figure out what to do next. I managed to get myself out...but didn't realize how hard the second part would be.

I don't know if that's the kind of thing you meant.

I'm sorta tempted to do the thing about scripts you said but I can't draw and don't have a scanner, so I don't know. And I should be looking for a job.